It’s Time We Talk About What Healthcare Really Is: Public Versus Personal Health

 

The general debate about how healthcare should be organized, measured, evaluated and paid for is about as useful as arguing about whether all food should be served hot, cold or room temperature.

Healthcare can be so many things these days, that I’m not even sure we agree on the definition of healthcare. We certainly have seen disagreements on what we expect our insurance policies to cover. This is an especially thorny question as we in the United States spend twice as much as any other country, and yet are worse off than the other industrialized nations in infant mortality, life expectancy and chronic disease burden statistics.

OBESITY AND SMOKING ARE NOW QUALITY INDICATORS, BUT ARE THEY TRULY THE DOCTOR’S RESPONSIBILITY?

The lines have blurred between public and personal health, and there have even been a couple of role reversals between medicine as we were trained to view it and what we used to think of as public health. For example, ancient physicians like Hippocrates put great emphasis on nutrition advice in sickness and health, but during my lifetime the government started telling us how many glasses of water to drink and what nutrients are good and bad for us. This was when the beginning obesity epidemic was blamed on high fat intake several decades ago by someone in the government. Since then, fat consumption has decreased steadily while obesity rates have increased. In a clever reversal of its stance, the government has now lobbed the ball back in the physicians’ court, since the official strategy misfired so profoundly. And they have cleverly built in a punitive mandate to make sure they don’t get handed back the responsibility for the epidemic they fueled with their ignorance. How?

Medicare now demands that physicians document a follow-up/action plan for every single obese patient they see. Is that really a priority for the individual doctor-patient encounter? Especially since there are no truly effective medical treatments for obesity. It is best treated with diet (higher fat, lower carbohydrate) and exercise. Or is it perhaps something better handled in the public health arena again, this time with better science behind it? When there is talk of shortages of primary care doctors as the baby boomer generation enters their senior years, as we struggle with high hospital readmission rates, and as we wring our hands over lack of access in primary care and inappropriate emergency room utilization, should we turn sick patients away because we are busy counseling even our most unwilling patients one by one on the dangers of soft drinks and breakfast cereals?

Similarly, smoking has been viewed as a public health problem, but it has now become a yardstick in healthcare, too. Doctors will now fail their quality metrics for any diabetic patient that smokes, regardless of their blood sugar, cholesterol and blood pressure control. Is that a fair and realistic way to measure physician performance? Will it cause “noncompliant” diabetics to lose access to care? I worry that it will.

Even gun safety has been put on the physicians’ shoulders. The Maine Medicaid well child visit templates have gun safety as a prescribed topic to cover. What the political parties have failed at, we are now supposed to do as an add-on item in our fifteen minutes with our patients. Interestingly though, a 2011 Florida law, which was upheld in a legal challenge this year, specifically prohibits physicians from asking their patients about gun ownership. So why is healthcare defined differently at the opposite ends of US Route One?

ARE IMMUNIZATIONS HEALTHCARE OR PUBLIC HEALTH?

Obvious Public health activities such as immunizing against contagious diseases were traditionally done by doctors’ offices in this country. In Sweden, where I trained, physicians in primary care did not usually administer childhood vaccines. Instead, publicly funded nurse-run clinics handled immunizations and routine screenings of infants and young children.

The difference I see between immunizations given in a government run clinic and in a physician’s office is that physicians, by nature of their training, tend to be patient focused and sometimes will support their patients’ decisions about forgoing immunizations, for example some of the newer, less studied vaccines that have much less than 25 years of study (it took about that long to find out if post menopausal estrogen decreased heart attack risk as it had been speculated – it actually increased it).

Now national pharmacy chains are giving adult immunizations with forceful promotion and obvious profit motives but physicians, who in some cases are losing the revenue from giving the shots, are still required to spend their time keeping track of who got what shot.

THE DIFFERENCE BETWEEN PUBLIC AND PERSONAL HEALTH

Public health puts the individual second and societal health, finances or well-being first. Doctors, just as in the example about immunizations above, have traditionally had an obligation first to their own patients. The more we are expected to be public health officials, the more our relationship with each patient may be challenged. We are also getting sucked into a pseudo-accountability that is more political than scientific. Just like we are measured by how many of our heart disease patients are on beta blockers and how many diabetics are on ACE inhibitors, both of which are considerations with some controversy and many exceptions, our public health and common-sense recommendations are now measured in absurdum. Even when it comes to what we say behind closed exam room doors to patients who drink too much or exercise too little, we are being measured as if we are the only ones on the planet who can tell our patients these things.

By holding physicians accountable for many of the global ills of our society, from obesity to smoking, alcohol use, distracted driving and sedentary lifestyles, we have entered an environment where others are doing or being considered for the jobs we were trained to do: Pharmacists treating hypertension, nurses dosing blood thinners, Nurse Practitioners seeing our sick patients at Walmart or CVS clinics. This will be the topic of my next post in the series “It’s Time We Talk…”

 

5 Responses to “It’s Time We Talk About What Healthcare Really Is: Public Versus Personal Health”


  1. 1 si September 25, 2014 at 1:50 am

    Dear Country Doctor:

    Your post “It’s Time We Talk About What Healthcare Really Is: Public Versus Personal Health” was especially thought-rpovoking and I tweeted it out several of my healthcare folks. We get together on Tuesday nights for a “Tweetchat” under #hcldr, and the folks that run it have a blog, post an article and several specific questions, and we try to have a discussion. Mostly it’s the “afterparty” that matters — we see get into longer conversations after the hour is over.

    I sent your blog post to one of the folks there, and to several of the physicians I respect, and one of them said “hands down one of my favorite reads.” It has been retweeted a number of times.

    Haven’t even tried to comment right on your blog as previous efforts on others’s have been for naught, but wanted you to know — many of us didn’t realize what the physician was being asked to do. Many of us (I am a former psychologist and have some stories as a clinician) as patients bemoan the change in our time with docs. Now I want to give you a hug and buy you a beer.

    Thanks for your writing. I don’t get to read everything that lands in my inbox of yours, but every time I read a post, I learn something that matters to me. Just wanted to let you know, and that I shared.

    Best wishes to you. I hope you sleep well.

  2. 2 Andrew_M_Garland September 25, 2014 at 6:45 am

    The following article from 2007 details a statistical confusion. The US has more death from acccidents and murder than its peers, among other causes. US infant mortality is higher primarily due to a strict reporting standard (all births, no matter how premature) and more premature and defective births from aggressive in-vitro fertalization.

    Total mortality is a bad measure of medical effectiveness. One might think that such organizations as the World Health Organization wanted the US to look bad. A government pushing ObamaCare might also want the (former?) capitalist health system to look bad.

    Natural Life Expectancy in the United States
    === ===
    [edited] The CDC’s (US Center For Disease Control) life expectancy figures also incorporate non-natural causes of death, such as those resulting from fatal injuries, which include motor vehicle accidents, falls, accidental poisonings, and homicides.

    These factors represent the leading causes of premature death in the United States for all ages up through 44 years old. Premature deaths caused by these non-natural factors result in a lower life expectancy figure for the U.S., which gives a somewhat misleading picture of the general health of U.S. individuals.

    Without accounting for the incidence of fatal injuries, the United States ties for 14th of the 16 nations listed. But once fatal injuries are taken into account, U.S. “natural” life expectancy from birth ranks first among the richest nations of the world.
    === ===

    The WHO (The UN World Health Organization) statistic that the US is 37th in health care efficacy is commonly repeated and is deeply misleading. See support for this is at USA health care is First – Infant Mortality is Low). The WHO offers various rankings. 37th is the most biased and political one, showing the worst result for the US. The WHO rankings are untrustworthy when you look under the surface at their methods, also at the link.

    The following video criticizes Canadian health care. Canada saves money by making patients wait and sometimes die before they can be treated. Sally C. Pipes understands and lived under Canada’s national health care system. She gives some personal stories and other facts.

    The Difference Between Canada and the U.S. Health Care Systems (video 7:34)

    The British National Health Service (NHS) is skimping on maternity care, but reports great statistics. This puzzles me.

    Bed shortage forces 4,000 mothers to give birth in lifts, offices, and hospital toilets
    08/26/09 – Daily Mail UK OnLine. (Via Don Surber)
    === ===
    [edited] Surber: Here is how free, socialist health care works in England. I thought their infant mortality rate was so much better. I mean, they would not lie about something like that. They spend half what the United States spends.
    == ===

    I am puzzled by multiple reports that the US spends much more than Europe on health care and gets much worse results. But, the above instances give me doubts. Supposedly, Europe spends less for better results, but how is this done? I never see details. Their bureaucrats have solved the problem, but won’t tell us how? What is the secret? Are they fudging their numbers like the US Vetreans Administration was lying about waiting times?

    If Europe spends less by delivering less, then that is not remarkable. If the US spends more because of runaway medical litigation and defensive medicine, then that is a legal problem, not a healthcare extravagance.

    The current ObamaCare plan is to reduce health care costs by just spending less. Just like people could reduce their food costs by eating less. Reducing health care costs by delivering less healthcare is not what I think people currently understand about the evolving US “health care system”.


  1. 1 Population Health: Our Lives, Our Data | hcldr Trackback on August 10, 2015 at 3:56 am
  2. 2 Population Health: Our lives, Our data | Bernadette Keefe MD Trackback on August 17, 2015 at 5:14 pm
  3. 3 Mayo Clinic Center for Innovation | Population Health: Our Lives, Our Data Trackback on September 17, 2015 at 5:01 pm

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